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Stereotactic radiosurgery for tremor: systematic review

International Stereotactic Radiosurgery Society practice guidelines

Nuria E. Martínez-Moreno, Arjun Sahgal, Antonio De Salles, Motohiro Hayashi, Marc Levivier, Lijun Ma, Ian Paddick, Jean Régis, Sam Ryu, Ben J. Slotman and Roberto Martínez-Álvarez

OBJECTIVE

The aim of this systematic review is to offer an objective summary of the published literature relating to stereotactic radiosurgery (SRS) for tremor and consensus guideline recommendations.

METHODS

This systematic review was performed up to December 2016. Article selection was performed by searching the MEDLINE (PubMed) and EMBASE electronic bibliographic databases. The following key words were used: “radiosurgery” and “tremor” or “Parkinson’s disease” or “multiple sclerosis” or “essential tremor” or “thalamotomy” or “pallidotomy.” The search strategy was not limited by study design but only included key words in the English language, so at least the abstract had to be in English.

RESULTS

A total of 34 full-text articles were included in the analysis. Three studies were prospective studies, 1 was a retrospective comparative study, and the remaining 30 were retrospective studies. The one retrospective comparative study evaluating deep brain stimulation (DBS), radiofrequency thermocoagulation (RFT), and SRS reported similar tremor control rates, more permanent complications after DBS and RFT, more recurrence after RFT, and a longer latency period to clinical response with SRS. Similar tremor reduction rates in most of the reports were observed with SRS thalamotomy (mean 88%). Clinical complications were rare and usually not permanent (range 0%–100%, mean 17%, median 2%). Follow-up in general was too short to confirm long-term results.

CONCLUSIONS

SRS to the unilateral thalamic ventral intermediate nucleus, with a dose of 130–150 Gy, is a well-tolerated and effective treatment for reducing medically refractory tremor, and one that is recommended by the International Stereotactic Radiosurgery Society.

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Yi-Chieh Hung, Cheng-Chia Lee, Huai-che Yang, Nasser Mohammed, Kathryn N. Kearns, Ahmed M. Nabeel, Khaled Abdel Karim, Reem M. Emad Eldin, Amr M. N. El-Shehaby, Wael A. Reda, Sameh R. Tawadros, Roman Liscak, Jana Jezkova, L. Dade Lunsford, Hideyuki Kano, Nathaniel D. Sisterson, Roberto Martínez Álvarez, Nuria E. Martínez Moreno, Douglas Kondziolka, John G. Golfinos, Inga Grills, Andrew Thompson, Hamid Borghei-Razavi, Tanmoy Kumar Maiti, Gene H. Barnett, James McInerney, Brad E. Zacharia, Zhiyuan Xu and Jason P. Sheehan

OBJECTIVE

The most common functioning pituitary adenoma is prolactinoma. Patients with medically refractory or residual/recurrent tumors that are not amenable to resection can be treated with stereotactic radiosurgery (SRS). The aim of this multicenter study was to evaluate the role of SRS for treating prolactinomas.

METHODS

This retrospective study included prolactinomas treated with SRS between 1997 and 2016 at ten institutions. Patients’ clinical and treatment parameters were investigated. Patients were considered to be in endocrine remission when they had a normal level of prolactin (PRL) without requiring dopamine agonist medications. Endocrine control was defined as endocrine remission or a controlled PRL level ≤ 30 ng/ml with dopamine agonist therapy. Other outcomes were evaluated including new-onset hormone deficiency, tumor recurrence, and new neurological complications.

RESULTS

The study cohort comprised 289 patients. The endocrine remission rates were 28%, 41%, and 54% at 3, 5, and 8 years after SRS, respectively. Following SRS, 25% of patients (72/289) had new hormone deficiency. Sixty-three percent of the patients (127/201) with available data attained endocrine control. Three percent of patients (9/269) had a new visual complication after SRS. Five percent of the patients (13/285) were recorded as having tumor progression. A pretreatment PRL level ≤ 270 ng/ml was a predictor of endocrine remission (p = 0.005, adjusted HR 0.487). An increasing margin dose resulted in better endocrine control after SRS (p = 0.033, adjusted OR 1.087).

CONCLUSIONS

In patients with medically refractory prolactinomas or a residual/recurrent prolactinoma, SRS affords remarkable therapeutic effects in endocrine remission, endocrine control, and tumor control. New-onset hypopituitarism is the most common adverse event.